The development of quality circles/peer review groups as a method of quality improvement in Europe. Results of a survey in 26 European countries

Changes in French family medicine residents' perspectives about patient partners' participation in teaching: A qualitative study in co-facilitated practice exchange groups

PURPOSE

The patient partner in teaching method is progressively developing for clinical training in France. Practice exchange groups (PEG) co-facilitated by patient partners in teaching are used during the training of family medicine (FM) residents. This study explored the FM residents' perspectives about patient partner in teaching's participation in co-facilitated PEGs and how they changed over time.

STUDENTS AND METHODS

In 2020, qualitative focus groups were carried out with 26 FM residents before and after a 5-month intervention based on monthly PEGs co-facilitated by patient partners in teaching. A reflective thematic analysis of the focus group interviews was performed according to Braun and Clarke's approach.

RESULTS

FM residents supported patient partners in teaching's facilitation role and had high expectations concerning their contribution to the development of their skills and competencies. They expected patient partners in teaching to bring their individual experience and also a collective knowledge. Some limitations mentioned by FM residents disappeared over time, such as the loss of the medical group feeling among physicians, while others persisted and required pedagogical support targeted to FM residents before PEG initiation.

CONCLUSION

This study shows the good acceptance of patient partners in teaching by FM residents in the context of PEGs. Attention should be paid to make FM residents aware of patient partners in teaching's missions before their introduction.

Development of indicators to assess quality and patient pathways in interdisciplinary care for patients with 14 ambulatory-care-sensitive conditions in Germany

BACKGROUND

In settings like the ambulatory care sector in Germany, where data on the outcomes of interdisciplinary health services provided by multiple office-based physicians are not always readily available, our study aims to develop a set of indicators of health care quality and utilization for 14 groups of ambulatory-care-sensitive conditions based on routine data. These may improve the provision of health care by informing discussions in quality circles and other meetings of networks of physicians who share the same patients.

METHODS

Our set of indicators was developed as part of the larger Accountable Care in Deutschland (ACD) project using a pragmatic consensus approach. The six stages of the approach drew upon a review of the literature; the expertise of physicians, health services researchers, and representatives of physician associations and statutory health insurers; and the results of a pilot study with six informal network meetings of office-based physicians who share the same patients.

RESULTS

The process resulted in a set of 248 general and disease specific indicators for 14 disease groups. The set provides information on the quality of care provided and on patient pathways, covering patient characteristics, physician visits, ambulatory care processes, pharmaceutical prescriptions and outcome indicators. The disease groups with the most indicators were ischemic heart diseases, diabetes and heart failure.

CONCLUSION

Our set of indicators provides useful information on patients' health care use, health care processes and health outcomes for 14 commonly treated groups of ambulatory-care-sensitive conditions. This information can inform discussions in interdisciplinary quality circles in the ambulatory sector and foster patient-centered care.

Using social network analysis methods to identify networks of physicians responsible for the care of specific patient populations

BACKGROUND

Coordinating health care within and among sectors is crucial to improving quality of care and avoiding undesirable negative health outcomes, such as avoidable hospitalizations. Quality circles are one approach to strengthening collaboration among health care providers and improving the continuity of care. However, identifying and including the right health professionals in such meetings is challenging, especially in settings with no predefined patient pathways. Based on the Accountable Care in Germany (ACD) project, our study presents a framework for and investigates the feasibility of applying social network analysis (SNA) to routine data in order to identify networks of ambulatory physicians who can be considered responsible for the care of specific patients.

METHODS

The ACD study objectives predefined the characteristics of the networks. SNA provides a methodology to identify physicians who have patients in common and ensure that they are involved in health care provision. An expert panel consisting of physicians, health services researchers, and data specialists examined the concept of network construction through informed decisions. The procedure was structured by five steps and was applied to routine data from three German states.

RESULTS

In total, 510 networks of ambulatory physicians met our predefined inclusion criteria. The networks had between 20 and 120 physicians, and 72% included at least ten different medical specialties. Overall, general practitioners accounted for the largest proportion of physicians in the networks (45%), followed by gynecologists (10%), orthopedists, and ophthalmologists (5%). The specialties were distributed similarly across the majority of networks. The number of patients this study allocated to the networks varied between 95 and 45,268 depending on the number and specialization of physicians per network.

CONCLUSIONS

The networks were constructed according to the predefined characteristics following the ACD study objectives, e.g., size of and specialization composition in the networks. This study shows that it is feasible to apply SNA to routine data in order to identify groups of ambulatory physicians who are involved in the treatment of a specific patient population. Whether these doctors are also mainly responsible for care and if their active collaboration can improve the quality of care still needs to be examined.

[Quality in statutory outpatient care: a modular system with varying approaches]

How is quality supported and what voluntary activities are there in the German statutory healthcare sector? Especially in outpatient healthcare, with a high proportion of chronic diseases treated that can significantly impair one's quality of life, quality of care is of utmost importance. We provide an overview of quality assurance measures that statutorily practicing doctors and psychotherapists (must) oblige to. Voluntary activities from third parties like doctor-specific associations and critical incidence reporting systems (CIRS) are presented alongside tools and services provided by the National and Regional Associations of Statutory Health Insurance Physicians as well as the implications of "Richtlinien" (directives) from the Federal Joint Committee and of "Qualitätssicherungsvereinbarungen" (quality assurance agreements) from the Joint Committee Quality Assurance. In summary, there is a wide spectrum of (in part voluntary) instruments and rules that is the cornerstone for the high quality present in the statutory outpatient healthcare system in Germany.

General practitioners' clinical practice on the management of cystitis in Normandy, France: A clinical vignettes-based study

RATIONALE, AIMS, AND OBJECTIVES

The objective was to measure the quality of clinical practice for the management of cystitis in adult women in general practice by collaborating with quality circles and the regional centre for antibiotic counsel.

METHOD

This descriptive cross-sectional study was performed in 2018 in Normandy, France. A questionnaire composed of clinical vignettes was used to evaluate practices of general practitioners (GPs) with regard to cystitis classified into four categories: simple, at risk of complication, recurrent, and caused by multidrug-resistant bacteria. The 2017 French Infectious Diseases Society's guidelines were used as a reference.

RESULTS

A total of 142 GPs participated in the study (45.5% of the solicited). Fosfomycin-trometamol and pivmecillinam were cited as first-line treatments for simple cystitis by 134 (94%) and 38 (27%) participants, respectively. For at risk of complication cystitis, the treatments cited were cefixime by 64 participants (45%), ofloxacin by 50 (35%), pivmecillinam by 49 (35%), fosfomycin-trometamol by 38 (27%), nitrofurantoin by 36 (25%), and amoxicillin-clavulanic acid by 28 (20%). Mean compliance rates were 85% for simple cystitis, 39% for at risk of complication cystitis, 60% for recurrent cystitis and 14% for cystitis caused by multidrug-resistant bacteria. Two criteria had less than 10% of the compliant answers: comprehensive knowledge of cystitis complication risk factors (9%) and positivity thresholds of urine cultures (10%).

CONCLUSIONS

In this study, diagnostic means, follow-up testing, and simple cystitis treatment (with fosfomycin predominantly mentioned) were broadly compliant. The use of critical antibiotics was too frequent for at risk of complication cystitis. There may be a need to improve the knowledge of professionals on antibiotic resistance and appropriate antibiotic use.

Developing measures to capture the true value of primary care

Primary care (PC) is an essential building block for any high quality healthcare system, and has a particularly positive impact on vulnerable patients. It contributes to the overall performance of health systems, and countries that reorient their health system towards PC are better prepared to achieve universal health coverage. Monitoring the actual performance of PC in health systems is essential health policy to support PC. However, current indicators are often too narrowly defined to account for quality of care in the complex populations with which PC deals. This article reviews a number of conceptual frameworks developed to capture PC values in robust measures and indicators that can inform policy and practice performance. Each have benefits and limitations. Further work is needed to develop meaningful primary health care (PHC) and PC measures to inform strategic action by policymakers and governments for improved overall performance of health systems.

How does small group continuing medical education (CME) impact on practice for rural GPs and their patients, a mixed-methods study

Studies which report outcomes of continuing medical education (CME) interventions for rural general practitioners (GPs) are limited. This mixed methods study recruited GPs from four CME small group learning (SGL) tutor groups based in different rural locations in the Republic of Ireland. A two-hour teaching module on deprescribing in older patients was devised and implemented. Assessment of educational outcomes was via questionnaires, prescribing audits and qualitative focus groups. All GPs (n = 43) in these CME-SGL groups agreed to participate, 27 of whom (63%) self-identified as being in rural practice. Rural GPs were more likely to be male (56%), in practice for longer (19 years), and attending CME for longer (13 years). The questionnaires indicated learning outcomes were achieved knowledge increased immediately after the education, and was maintained 6 months later. Twenty-four GPs completed audits involving 191 patients. Of these, 152 (79.6%) were de-prescribed medication. In the qualitative focus groups, GPs reported sharing experiences with their peers during CME-SGL helped them to improve patient care and ensured that clinical practice is more consistent across the group. For rural GPs, CME-SGL involving discussion of cases and the practical implementation of guidelines, associated with audit, can lead to changes in patient care.

Where do Peer Review Groups fit in the international Continuing Professional Development literature?

OBJECTIVES

To describe what is reported in the Continuing Professional Development (CPD) literature on small group learning formats in medicine, including the Royal Australian and New Zealand College of Psychiatrists (RANZCP) CPD Peer Review Groups (PRGs).

METHOD

A literature review of international peer-reviewed publications in relation to the use of small group learning formats for CPD in medicine.

RESULTS

Small groups are commonly used as a learning format in medical CPD, primarily in general practice, but are little researched. Such groups take differing forms and they are valued by participants for a range of purposes, having effects on professionalism, clinical performance and doctors' wellbeing.

CONCLUSION

We believe that the contribution of these groups to medical CPD should be further explored. To this end, this review forms the first part of a research project focussing on the RANZCP PRG model used by Australian and New Zealand psychiatrists.

Offering patients a choice for colorectal cancer screening: a quality improvement pilot study in a quality circle of primary care physicians

Background

Guidelines recommend primary care physicians (PCPs) offer patients a choice between colonoscopy and faecal immunochemical test (FIT) for colorectal cancer (CRC) screening. Patients choose almost evenly between both tests but in Switzerland, most are tested with colonoscopy while screening rates are low. A quality circle (QC) of PCPs is an ideal site to train physicians in shared decision-making (SDM) that will help more patients decide if they want to be tested and choose the test they prefer.

Objective

Systematically assess CRC screening status of eligible 50–75 y.o. patients and through SDM increase the proportion of patients who have the opportunity to choose CRC screening and the test (FIT or colonoscopy).

Methods

Working through four Plan-Do-Study-Act (PDSA) cycles in their QC, PCPs adapted tools for SDM and surmounted organisational barriers by involving practice assistants. Each PCP included 20, then 40 consecutive 50–75 y.o. patients, repeatedly reported CRC status as well as the proportion of eligible patients with whom CRC screening could be discussed and patients’ decisions.

Results

9 PCPs initially included 176, then 320 patients. CRC screening status was routinely noted in the electronic medical record and CRC screening was implemented in daily routine, increasing eligible patients’ chance to be offered screening. Over a year, screening rates trended upwards, from 37% to 40% (p=0.46) and FIT use increased (2%–7%, p=0.008). Initially, 7/9 PCPs had no patient ever tested with FIT; after the intervention, only 2/8 recorded no FIT tests.

Conclusions

Through data-driven PDSA cycles and significant organisational changes, PCPs of a QC systematically collected data on CRC screening status and implemented SDM tools in their daily routine. This increased patients’ chance to discuss CRC screening. The more balanced use of FIT and colonoscopy suggests that patients’ values and preferences were better respected.

Veterinary peer study groups as a method of continuous education-A new approach to identify and address factors associated with antimicrobial prescribing

Within the dairy industry, most antimicrobials are used for dry-cow therapy or mastitis treatment. To reduce antimicrobial usage in dairy cows, increasing awareness and behaviour change is necessary. As veterinarians are known to be influenced by their peers, peer study groups as a continuous education might contribute to this. Therefore, the objective of this study was to analyse written records of veterinary peer study group meetings to identify factors associated with antimicrobial prescribing decisions, and to analyse veterinarians' attitude towards the benefits of this continuous education method. Twenty-three participating Swiss cattle practitioners were divided into three groups. Each group met every two to five months, together with a facilitator and an expert on the topic to be discussed. Written records from every meeting were taken and analysed qualitatively to identify factors influencing veterinarians' decisions on antimicrobial prescribing and mastitis therapy. In addition, focus group discussions were conducted after the last meeting, to assess the veterinarians' learning achievements gained during the peer study group meetings. Extrinsic factors such as external pressure, competition, farmer, individual animal, farm and diagnostics as well as intrinsic factors such as own experience/attitude, knowledge and change of mindset during career could be shown to influence veterinarians' decisions on antimicrobial prescribing. In the focus group discussions, the veterinarians stated that they gained new knowledge, received new stimuli, exchanged with their peers and felt supported in their relationship to their farmers. Since the identified factors are partly interrelated, it is not sufficient to change a single factor to achieve a change in the antimicrobial prescription behaviour of veterinarians. Veterinary peer study groups could contribute to the intention to change, because veterinarians experienced multiple benefits from this method of continuous education. In order to quantify this, the prescription data of the veterinarians are analysed in a next step.

Use of quality circles for primary care providers in 24 European countries: an online survey of European Society for Quality and Safety in family practice delegates

Objective: To identify and describe the core characteristics and the spread of quality circles in primary healthcare in European countries. Design: An online survey was conducted among European Society for Quality and Safety in Family Practice (EQuiP) delegates. To allow comparison with earlier results, a similar survey as in a study from 2000 was used. Setting: Primary Health Care in European countries. Subjects: General practitioners, delegated experts of the European Society for Quality and Safety in Family Practice (EQuiP). Main outcome measures: (1) Attendance in quality circles (2) their objectives (3) methods of quality improvement quality circles use (4) facilitator's role and training (5) role of institutions (6) supporting material and data sources quality circles use. Results: 76% of the delegates responded, representing 24 of 25 countries. In 13 countries, more than 10% of general practitioners participated in quality circles, compared with eight countries in 2000. The focus of quality circles moved from continuous medical education to quality improvement. Currently, quality circles groups use case-based discussions, educational materials and local opinion leaders in addition to audit and feedback. Some national institutions provide training for facilitators and data support for quality circle groups. Conclusion: The use of quality circles has increased in European countries with a shift in focus from continuous medical education to quality improvement. Well-trained facilitators are important, as is the use of varying didactic methods and quality improvement tools. Qualitative inquiry is necessary to examine why QCs thrive or fail in different countries and systems. KEY POINTS Countries with already established quality circle movements increased their participation rate and extended their range of quality circle activities The focus of quality circles has moved from CME/CPD to quality improvement Well-trained facilitators are important, as is the use of varying didactic methods and quality improvement tools Institutions should provide supporting material and training for facilitators.

Adherence to guideline recommendations for asthma care in community pharmacies: actual and needed performance

Pharmaceutical care guidelines aim to provide recommendations for pharmaceutical care, reduce unwanted pharmacy practice variation and ultimately improve the quality of healthcare. This study evaluated community pharmacists’ adherence to recommendations for the provision of care to asthma patients with first dispensing and follow-up refill encounters in The Netherlands. Data were pharmacists’ self-assessment of adherence to guideline recommendations, independent observations of dispensing encounters and a nationwide questionnaire on pharmacists’ views on the desirable (clinical) necessity of applying guideline recommendations to their patient population. The 21 pharmacists who performed self-assessment judged their adherence concerning inhalation instructions as high. The lowest scores were reported for recommendations to collect additional information on the type of lung disease and for asking patients’ expectations, wishes and concerns. Sixty-eight dispensing encounters were observed. In 83% of the 35 first dispensing observations, inhalation instruction was provided. This percentage was lower (62%) at refill dispensings. During all encounters, pharmacy staff seldom explored patients’ perceptions or responded to patients’ expectations, wishes and concerns. One hundred and four pharmacists completed the feasibility questionnaire. Pharmacists judged that all patients should receive inhalation instruction at first dispensing. They regarded it necessary to check on patients’ expectations, wishes and concerns regarding the treatment for only up to 70% of the patients. More efforts on guideline implementation are needed, especially on follow-up dispensings and on gaining relevant information from patients and other healthcare professionals. Pharmacists still have opportunities to grow in applying a patient-tailored approach and exploring patients’ individual needs, rather than providing practical information.

Improving the implementation of patient safety by nursing students using nursing instructors trained in the use of quality circles

Background

It is recognised worldwide that the skills of nursing students concerning patient safety is still not optimal. The role of clinical instructors is to instil in students the importance of patient safety. Therefore, it is important to have competent clinical instructors. Their experience can be enhanced through the application of quality circles. This study identifies the effect of quality circles on improving the safety of patients of nursing students. Patient safety is inseparable from the quality of nursing education. Existing research shows that patient safety should be emphasised at all levels of the healthcare education system. In hospitals, the ratio between nursing students and clinical instructors is disproportionately low. In Indonesia, incident data relating to patient safety involving students is not well documented, and the incidents often occur in the absence of a clinical instructor.

Methods

This study used a quasi-experimental research design with pre-test and post-test non-equivalent control groups. The aim of the project was to explore the implications of the quality circle on clinical instructors by comparing the students’ knowledge, attitudes, and practices of control and intervention groups. A questionnaire will be conducted to evaluate the implementation of patient safety and the impact of the intervention. The data were statistically analysed using independent t tests. The intervention was the implementation of quality circles that focused on patient safety issues for the use of clinical instructors to assess and guide student nurse behaviour in regard to patient safety. The authors of this study trained the clinical instructors on how to use quality circle methods to solve nursing problems especially with relevance to the patient safety issues of students.

Results

The results showed a significant increase in the behaviour of nursing students towards patient safety issues (p < 0.001; α = 0.05).

Conclusions

The implementation of quality circles has a significant effect on patient safety. Therefore, it is recommended to implement quality circles as a problem-solving technique to optimize patient safety.

Quality circles for quality improvement in primary health care: Their origins, spread, effectiveness and lacunae- A scoping review

Quality circles or peer review groups, and similar structured small groups of 6–12 health care professionals meet regularly across Europe to reflect on and improve their standard practice. There is debate over their effectiveness in primary health care, especially over their potential to change practitioners’ behaviour. Despite their popularity, we could not identify broad surveys of the literature on quality circles in a primary care context. Our scoping review was intended to identify possible definitions of quality circles, their origins, and reported effectiveness in primary health care, and to identify gaps in our knowledge. We searched appropriate databases and included any relevant paper on quality circles published until December 2017. We then compared information we found in the articles to that we found in books and on websites. Our search returned 7824 citations, from which we identified 82 background papers and 58 papers about quality circles. We found that they originated in manufacturing industry and that many countries adopted them for primary health care to continuously improve medical education, professional development, and quality of care. Quality circles are not standardized and their techniques are complex. We identified 19 papers that described individual studies, one paper that summarized 3 studies, and 1 systematic review that suggested that quality circles can effectively change behaviour, though effect sizes varied, depending on topic and context. Studies also suggested participation may affirm self-esteem and increase professional confidence. Because reports of the effect of quality circles on behaviour are variable, we recommend theory-driven research approaches to analyse and improve the effectiveness of this complex intervention.

Interventions for improving management of chronic non-communicable diseases in Dikgale, a rural area in Limpopo Province, South Africa

Background

Chronic disease management (CDM) is an approach to health care that keeps people as healthy as possible through the prevention, early detection and management of chronic diseases. The aim of this study was to develop interventions to improve management of chronic diseases in the form of an integrated, evidence-based chronic disease management model in Dikgale, a rural area of Limpopo Province in South Africa.

Methods

A multifaceted intervention, called ‘quality circles’ (QCs) was developed to improve the quality and the management of chronic diseases in the Dikgale Health and Demographic Surveillance System (HDSS). These QCs used the findings from previous studies which formed part of the larger project in the study area, namely, the quantitative study using STEPwise survey and qualitative studies using focus group discussions and semi-structured interviews.

Results

The findings from previous studies in Dikgale HDSS revealed that an epidemiological transition is occurring. Again, the most widely reported barriers from previous studies in this rural area were: lack of knowledge of NCDs; shortages of medication and shortages of nurses in the clinics, which results in patients having long waiting-time at clinics. Lack of training of health care providers on the management of chronic diseases and the lack of supervision by the district and provincial health managers, together with poor dissemination of guidelines, were contributing factors to the lack of knowledge of non-communicable diseases (NCDs) management among nurses and community health care workers (CHWs). Consideration of all of these findings led to the development of model which focuses on integrating nursing services, CHWs and traditional health practitioners (THPs), including a well-established clinical information system for health care providers. A novel aspect of the model is the inclusion of community ambassadors who are on treatment for NCDs and are, thus, repositories of knowledge who can serve as a bridge between health care workers and community members.

Conclusion

The model developed highlights the need for health interventions that aim to control risk factors at the population level, the need for availability of NCD-trained nurses, functional equipment and medication and a need to improve the link with traditional healers.

Effect of audit and feedback with peer review on general practitioners' prescribing and test ordering performance: a cluster-randomized controlled trial

BACKGROUND

Much research worldwide is focussed on cost containment and better adherence to guidelines in healthcare. The research focussing on professional behaviour is often performed in a well-controlled research setting. In this study a large-scale implementation of a peer review strategy was tested on both test ordering and prescribing behaviour in primary care in the normal quality improvement setting.

METHODS

We planned a cluster-RCT in existing local quality improvement collaboratives (LQICs) in primary care. The study ran from January 2008 to January 2011. LQICs were randomly assigned to one of two trial arms, with each arm receiving the same intervention of audit and feedback combined with peer review. Both arms were offered five different clinical topics and acted as blind controls for the other arm. The differences in test ordering rates and prescribing rates between both arms were analysed in an intention-to-treat pre-post analysis and a per-protocol analysis.

RESULTS

Twenty-one LQIC groups, including 197 GPs working in 88 practices, entered the trial. The intention-to-treat analysis did not show a difference in the changes in test ordering or prescribing performance between intervention and control groups. The per-protocol analysis showed positive results for half of the clinical topics. The increase in total tests ordered was 3% in the intervention arm and 15% in the control arm. For prescribing the increase in prescriptions was 20% in the intervention arm and 66% in the control group. It was observed that the groups with the highest baseline test ordering and prescription volumes showed the largest improvements.

CONCLUSIONS

Our study shows that the results from earlier work could not be confirmed by our attempt to implement the strategy in the field. We did not see a decrease in the volumes of tests ordered or of the drugs prescribed but were able to show a lesser increase instead. Implementing the peer review with audit and feedback proved to be not feasible in primary care in the Netherlands.

TRIAL REGISTRATION

This trial was registered at the Dutch trial register under number ISRCTN40008171 on August 7^th 2007.

The Reasons behind the (Non)Use of Feedback Reports for Quality Improvement in Physical Therapy: A Mixed-Method Study

OBJECTIVES

To explain the use of feedback reports for quality improvements by the reasons to participate in quality measuring projects and to identify barriers and facilitators.

DESIGN

Mixed methods design.

METHODS

In 2009-2011 a national audit and feedback system for physical therapy (Qualiphy) was initiated in the Netherlands. After each data collection round, an evaluation survey was held amongst its participants. The evaluation survey data was used to explain the use of feedback reports by studying the reasons to participate with Qualiphy with correlation measures and logistic regression. Semi-structured interviews with PTs served to seek confirmation and disentangle barriers and facilitators.

RESULTS

Analysis of 257 surveys (response rate: 42.8%) showed that therapists with only financial reasons were less likely to use feedback reports (OR = 0.24;95%CI = 0.11-0.52) compared to therapists with a mixture of reasons. PTs in 2009 and 2010 were more likely to use the feedback reports for quality improvement than PTs in 2011 (OR = 2.41;95%CI = 1.25-4.64 respectively OR = 3.28;95%CI = 1.51-7.10). Changing circumstances in 2011, i.e. using EHRs and financial incentives, had a negative effect on the use of feedback reports (OR = 0.40, 95%CI = 0.20-0.78). Interviews with 12 physical therapists showed that feedback reports could serve as a tool to support and structure quality improvement plans. Barriers were distrust and perceived self-reporting bias on indicator scores.

CONCLUSIONS

Implementing financial incentives that are not well-specified and well-targeted can have an adverse effect on using feedback reports to improve quality of care. Distrust is a major barrier to implementing quality systems.

Can pay for performance improve the quality of primary care?

Martin Roland and Frede Olesen explore what other countries can learn from the UK’s experience with the Quality and Outcomes Framework

Factors associated with GPs' knowledge of their patients' socio-economic circumstances: a multilevel analysis

BACKGROUND

To determine appropriate management for individual patients, GPs are supposed to use their knowledge of the patient's socio-economic circumstances.

OBJECTIVE

To analyse factors associated with GPs' knowledge of these circumstances.

METHODS

Observational survey of GPs who were internship supervisors in the Paris metropolitan area. Each of 52 volunteer GPs completed a self-administered questionnaire about their own characteristics and randomly selected 70 patients from their patient list. Their knowledge was analysed as the agreement between the patients' and GPs' responses to questions about the patients' socio-economic characteristics in questionnaires completed by both groups. The association between agreement and the GPs' characteristics was analysed with a multilevel model adjusted for age, sex and the duration of the GP-patient relationship.

RESULTS

Agreement varied according to the socio-economic characteristics considered (from 51% to 90%) and between GPs. Globally, the GPs overestimated their patients' socio-economic level. GP characteristics associated with better agreement were sex (female), long consultations, the use of paper records or an automatic reminder system and participation in continuing medical education and in meetings to discuss difficult cases.

CONCLUSION

Knowledge of some patient characteristics, such as their complementary health insurance coverage or perceived financial situation, should be improved because their overestimation may lead to care that is too expensive and thus result in the patients' abandonment of the treatment. Besides determining ways to help GPs to organize their work more effectively, it is important to study methods to help doctors identify their patients' social-economic circumstances more accurately in daily practice.

Twelve tips for developing, implementing, and sustaining medical education fellowship programs: Building on new trends and solid foundations

Medical education fellowship programs (MEFPs) are a form of faculty development contributing to an organization's educational mission and participants' career development. Building an MEFP requires a systematic design, implementation, and evaluation approach which aligns institutional and individual faculty goals. Implementing an MEFP requires a team of committed individuals who provide expertise, guidance, and mentoring. Qualified MEFP directors should utilize instructional methods that promote individual and institutional short and long term growth. Directors must balance the use of traditional design, implementation, and evaluation methodologies with advancing trends that may support or threaten the acceptability and sustainability of the program. Drawing on the expertise of 28 MEFP directors, we provide twelve tips as a guide to those implementing, sustaining, and/or growing a successful MEFP whose value is demonstrated by its impacts on participants, learners, patients, teaching faculty, institutions, the greater medical education community, and the population's health.

Medical wikis dedicated to clinical practice: a systematic review

BACKGROUND

Wikis may give clinician communities the opportunity to build knowledge relevant to their practice. The only previous study reviewing a set of health-related wikis, without specification of purpose or audience, globally showed a poor reliability.

OBJECTIVE

Our aim was to review medical wiki websites dedicated to clinical practices.

METHODS

We used Google in ten languages, PubMed, Embase, Lilacs, and Web of Science to identify websites. The review included wiki sites, accessible and operating, having a topic relevant for clinical medicine, targeting physicians or medical students. Wikis were described according to their purposes, platform, management, information framework, contributions, content, and activity. Purposes were classified as "encyclopedic" or "non-encyclopedic". The information framework quality was assessed based on the Health On the Net (HONcode) principles for collaborative websites, with additional criteria related to users' transparency and editorial policy. From a sample of five articles per wikis, we assessed the readability using the Flesch test and compared articles according to the wikis' main purpose. Annual editorial activities were estimated using the Google engine.

RESULTS

Among 25 wikis included, 11 aimed at building an encyclopedia, five a textbook, three lessons, two oncology protocols, one a single article, and three at reporting clinical cases. Sixteen wikis were specialized with specific themes or disciplines. Fifteen wikis were using MediaWiki software as-is, three were hosted by online wiki farms, and seven were purpose-built. Except for one MediaWiki-based site, only purpose-built platforms managed detailed user disclosures. The owners were ten organizations, six individuals, four private companies, two universities, two scientific societies, and one unknown. Among 21 open communities, 10 required users' credentials to give editing rights. The median information framework quality score was 6 out of 16 (range 0-15). Beyond this score, only one wiki had standardized peer-reviews. Physicians contributed to 22 wikis, medical learners to nine, and lay persons to four. Among 116 sampled articles, those from encyclopedic wikis had more videos, pictures, and external resources, whereas others had more posology details and better readability. The median creation year was 2007 (1997-2011), the median number of content pages was 620.5 (3-98,039), the median of revisions per article was 17.7 (3.6-180.5) and 0.015 of talk pages per article (0-0.42). Five wikis were particularly active, whereas six were declining. Two wikis have been discontinued after the completion of the study.

CONCLUSIONS

The 25 medical wikis we studied present various limitations in their format, management, and collaborative features. Professional medical wikis may be improved by using clinical cases, developing more detailed transparency and editorial policies, and involving postgraduate and continuing medical education learners.

The challenge of transferring an implementation strategy from academia to the field: a process evaluation of local quality improvement collaboratives in Dutch primary care using the normalization process theory

RATIONALE, AIMS AND OBJECTIVES

A quality improvement strategy consisting of comparative feedback and peer review embedded in available local quality improvement collaboratives proved to be effective in changing the test-ordering behaviour of general practitioners. However, implementing this strategy was problematic. We aimed for large-scale implementation of an adapted strategy covering both test ordering and prescribing performance. Because we failed to achieve large-scale implementation, the aim of this study was to describe and analyse the challenges of the transferring process.

METHODS

In a qualitative study 19 regional health officers, pharmacists, laboratory specialists and general practitioners were interviewed within 6 months after the transfer period. The interviews were audiotaped, transcribed and independently coded by two of the authors. The codes were matched to the dimensions of the normalization process theory.

RESULTS

The general idea of the strategy was widely supported, but generating the feedback was more complex than expected and the need for external support after transfer of the strategy remained high because participants did not assume responsibility for the work and the distribution of resources that came with it.

CONCLUSION

Evidence on effectiveness, a national infrastructure for these collaboratives and a general positive attitude were not sufficient for normalization. Thinking about managing large databases, responsibility for tasks and distribution of resources should start as early as possible when planning complex quality improvement strategies. Merely exploring the barriers and facilitators experienced in a preceding trial is not sufficient. Although multifaceted implementation strategies to change professional behaviour are attractive, their inherent complexity is also a pitfall for large-scale implementation.

Effectiveness of peer assessment for implementing a Dutch physical therapy low back pain guideline: cluster randomized controlled trial

BACKGROUND

Clinical practice guidelines are considered important instruments to improve quality of care. However, success is dependent on adherence, which may be improved using peer assessment, a strategy in which professionals assess performance of their peers in a simulated setting.

OBJECTIVE

The aim of this study was to determine whether peer assessment is more effective than case-based discussions to improve knowledge and guideline-consistent clinical reasoning in the Dutch physical therapy guideline for low back pain (LBP).

DESIGN

A cluster randomized controlled trial was conducted.

SETTING AND PARTICIPANTS

Ten communities of practice (CoPs) of physical therapists were cluster randomized (N=90): 6 CoPs in the peer-assessment group (n=49) and 4 CoPs in the case-based discussion group (control group) (n=41).

INTERVENTION

Both groups participated in 4 educational sessions and used clinical patient cases. The peer-assessment group reflected on performed LBP management in different roles. The control group used structured discussions.

MEASUREMENTS

Outcomes were assessed at baseline and at 6 months. The primary outcome measure was knowledge and guideline-consistent reasoning, measured with 12 performance indicators using 4 vignettes with specific guideline-related patient profiles. For each participant, the total score was calculated by adding up the percentage scores (0-100) per vignette, divided by 4. The secondary outcome measure was reflective practice, as measured by the Self-Reflection and Insight Scale (20-100).

RESULTS

Vignettes were completed by 78 participants (87%). Multilevel analysis showed an increase in guideline-consistent clinical reasoning of 8.4% in the peer-assessment group, whereas the control group showed a decline of 0.1% (estimated group difference=8.7%, 95% confidence interval=3.9 to 13.4). No group differences were found on self-reflection.

LIMITATIONS

The small sample size, a short-term follow-up, and the use of vignettes as a proxy for behavior were limitations of the study.

CONCLUSIONS

Peer assessment leads to an increase in knowledge and guideline-consistent clinical reasoning.

Exploring why quality circles work in primary health care: a realist review protocol

BACKGROUND

Quality circles (QCs) are commonly used in primary health care in Europe to consider and improve standard practice over time. They represent a complex social intervention that occurs within the fast-changing system of primary health care. Numerous controlled trials, reviews, and studies have shown small but unpredictable positive effect sizes on behavior change. Although QCs seem to be effective, stakeholders have difficulty understanding how the results are achieved and in generalizing the results with confidence. They also lack understanding of the active components of QCs which result in changes in the behavior of health care professionals. This protocol for a realist synthesis will examine how configurations of components and the contextual features of QCs influence their performance.

METHODS/DESIGN

Stakeholder interviews and a scoping search revealed the processes of QCs and helped to describe their core components and underlying theories. After clarifying their historical and geographical distribution, a purposive and systematic search was developed to identify relevant papers to answer the research questions, which are: understanding why, how, and when QCs work, over what time frame, and in what circumstances. After selecting and abstracting appropriate data, configurations of contexts and mechanisms which influence the outcome of QCs within each study will be identified. Studies will be grouped by similar propositional statements in order to identify patterns and validation from stakeholders sought. Finally, theories will be explored in order to explain these patterns and to help stakeholders maintain and improve QC performance.

DISCUSSION

Analyzing context-mechanism-outcome (CMO) patterns will reveal how QCs work and how contextual factors interact to influence their outcome. The aim is to investigate unique configurations that enable them to improve the performance of health care professionals. Using a standardized reporting system, this realist review will allow the research questions to be answered to the satisfaction of key stakeholders and enable on-going critical examination and dissemination of the findings.

STUDY REGISTRATION

PROSPERO registration number: CRD42013004826.

Effects of reviewing routine practices on learning outcomes in continuing education

CONTEXT

Conventional continuing medical education (CME) has been shown to have modest effects on doctor performance. New educational approaches based on the review of routine practices have brought better results. Little is known about factors that affect the outcomes of these approaches, especially in middle-income countries. This study aimed to investigate factors that influence the learning and quality of clinical performance in CME based on reflection upon experiences.

METHODS

A questionnaire and a clinical performance test were administered to 165 general practitioners engaged in a CME programme in Brazil. The questionnaire assessed behaviours related to four input variables (individual reflection on practices, peer review of experiences, self-regulated learning and learning skills) and two mediating variables (identification of learning needs and engagement in learning activities, the latter consisting of self-study of scientific literature, consultations about patient problems, and attendance at courses). Structural equation modelling was used to test a hypothesised model of relationships between these variables and the outcome variable of clinical performance, measured by the clinical performance test.

RESULTS

After minor adjustments, the hypothesised model fit the empirical data well. Individual reflection fostered identification of learning needs, but also directly positively influenced the quality of clinical performance. Peer review did not affect identification of learning needs, but directly positively affected clinical performance. Learning skills and self-regulation did not help in identifying learning needs, but self-regulation enhanced study of the scientific literature, the learning activity that most positively influenced clinical performance. Consultation with colleagues, the activity most frequently triggered by the identification of learning needs, did not affect performance, and attendance of courses had only limited effect.

CONCLUSIONS

This study shed light on the factors that influence learning and performance improvement in continuing education based on the review of routine practices in middle-income settings. The findings support the importance of reflection on practices as an instrument for enhancing clinical performance.

Quality circles for pharmacotherapy to modify general practitioners' prescribing behaviour for generic drugs

RATIONALE, AIMS AND OBJECTIVES

In Austria, the participation of general practitioners (GPs) in so-called 'quality circles for pharmacotherapy' (QCPs) was taken as a special approach to increase the use of generics and possibly, to improve the quality and efficiency of prescribing patterns in primary care. This study aimes at exploring GPs' perception of QCPs whether they think that taking part has helped to change their prescribing habits, their opinions on generics in general and the issues that arise for them in attempting to promote their use.

METHODS

Qualitative analysis was used to evaluate QCP protocols for their potential to evoke discussion in the group and for their relevance to our study questions.

RESULTS

Of the 821 self-employed GPs in Vienna under contract with the Vienna District Health Insurance Fund 445 took part at least once in the study period. Seven main topics, which provide insight into various aspects of patient care in primary care, were identified: QCPs work, generic drug prescription, problems related to the sale of generics, patient counselling and education, therapy adherence, coordination of care, competence and medical education. From all prescribed drugs for which generics were available in the fourth quarter of the year 2003 GPs prescribed 33.91% generics, in the fourth quarter of 2004 43.97%, in the fourth quarter of 2005 46.31%, and in the fourth quarter of 2006 49.88%.

CONCLUSIONS

Peer review groups can be an important method of quality improvement in GPs' prescribing behaviour in favour of generics. QCPs also facilitate the exchange between GPs on problems encountered and provide feedback to policy makers.

CD-ROM continuous medical education model for the management of urinary tract infections in family practice

OBJECTIVES

This study had for aim to assess the acceptability of a model for continuing medical education, to improve the implementation of best practice recommendations for family practice. The training focused on the management of community acquired urinary tract infections in adults. The secondary objective was to identify barriers in the implementation of these best practice recommendations.

METHODS

We conducted a prospective qualitative study. The intervention included an initial knowledge test, an audio-visual CD-ROM presentation, and a second knowledge test. After the session, family practitioners (FP) were asked to answer a face-to-face questionnaire in order to give their opinion on the training session. Ten FP, working in the Savoie and Isère sub-divisions in France, were included.

RESULTS

All FP were satisfied with the e-learning training session. The element of the session, they best appreciated, was the audio-visual presentation. The comparison between initial and second test results showed a non-significant improvement of knowledge (P=0.07). The barriers, most frequently mentioned for knowledge and use of best practice recommendations, were: lack of time, content unfit for family practice, habits, and the very broad field of expertise required.

CONCLUSION

FP accepted this model of continuing medical education. E-learning seems relevant to improve the implementation of best practice recommendations in family practice.

[Peer groups: a model for the continuous professional development in general practice]

AIM

The purposes of this study were to analyse the peer groups' activity and functioning in General Practice in Isere department, the participants' characteristics, and their opinion on this activity.

METHODS

A census of existing groups was realized by asking professional organisations to provide us a complete list of the groups in the department. For each group, a member was asked to answer a questionnaire about the institution. Each general practitioner (GP) participating to a group was sent a questionnaire about his profile and was asked to give his personal opinion on the group.

RESULTS

The group inventory was difficult to realize, as no organisation was able to give us a complete list. Sixteen groups were included in the study, involving a total of 131 GPs. Groups were 1 to 10 years old, most of them were independent. The mean number of meetings was eight times a year. Participants were more often females, new graduates or young doctors, and internship supervisors. They were highly satisfied about this activity which allowed them to increase the quality of patient care (98%), and to change their practice (75%).

CONCLUSION

This study showed that peer group activity was growing in Isere. It was widely welcomed by GPs, who wondered in which way those groups could satisfy the obligations of professional development mentioned in the 2009 French law: Hospital, Patient, Health, Territory (HPST).

Intern culture, internal resistance: uptake of peer review in two Australian hospital internship programs

OBJECTIVE

To compare the uptake of peer review among interns in mandatory and voluntary peer-review programs.

POPULATION

All first and second year graduates (n=105) in two Australian hospitals.

MAIN OUTCOME MEASURES

Completion of peer review, and reported responses by doctors to peer review.

RESULTS

Eight of sixty interns undertaking the mandated program completed all steps. In the voluntary program, none of 45 interns did so. Resistance to peer review occurred at all stages of the trial, from the initial briefing sessions to the provision of peer-review reports. DISCUSSION; Hospital internship is a critical period for the development of professional identity among doctors. We hypothesise that resistance to peer review among novice doctors reflects a complex tension between the processes underpinning the development of a group professional identity in hospital, and a managerial drive for personal reflection and accountability. Peer review may be found threatening by interns because it appears to run counter to collegiality or 'team culture'. In this study, resistance to peer review represented a low-cost strategy in which the interns' will could be asserted against management.

CONCLUSION

To enhance uptake, peer review should be structured as key to clinical development, and modelled as a professional behaviour by higher-status colleagues.

Supervision--growing and building a sustainable general practice supervisor system

This article explores various models and ideas for future sustainable general practice vocational training supervision in Australia. The general practitioner supervisor in the clinical practice setting is currently central to training the future general practice workforce. Finding ways to recruit, retain and motivate both new and experienced GP teachers is discussed, as is the creation of career paths for such teachers. Some of the newer methods of practice-based teaching are considered for further development, including vertically integrated teaching, e-learning, wave consulting and teaching on the run, teaching teams and remote teaching. Approaches to supporting and resourcing teaching and the required infrastructure are also considered. Further research into sustaining the practice-based general practice supervision model will be required.

Impact of medical audit on electrodiagnostic medicine in polyneuropathy

OBJECTIVE

The aim of the study was to investigate whether experienced physicians' electrodiagnostic practice and criteria can be influenced by international collaboration involving peer review medical audit.

METHODS

Data was obtained from the ESTEEM project, an ongoing collaboration since 1991 among European neurophysiologists concerned with quality improvement in electrodiagnostic medicine. Three sets of the physicians' polyneuropathy examinations performed with intervals of 2-4 years were analysed.

RESULTS

Changes towards increased homogeneity among the physicians were found in (1) the average number of studies performed per patient and the number of abnormal studies required for accepting the diagnosis of polyneuropathy, with the most pronounced changes seen for abnormal motor nerve segments, abnormal F-wave studies, and electromyographic studies, and (2) the agreement on pathophysiological interpretation of nerve conduction studies and classification of polyneuropathy.

CONCLUSIONS

Changes towards increased homogeneity contributed to years of participation in peer review medical audit, were seen among a group of experienced physicians. Peer review medical audit as carried out here is however difficult to scale up. Therefore guidelines or minimal criteria should ideally supplement a medical audit process to disseminate the results obtained to a larger audience.

SIGNIFICANCE

These results support the role of international peer review medical audit in quality improvement of electrodiagnostic medicine.

Redes integradas, programas de gestão clínica e generalista coordenador: análise das reformas recentes do setor ambulatorial na Alemanha

O fortalecimento do papel do generalista na condução e coordenação de cuidados especializados, hospitalares e sociais para garantir a continuidade é tendência observada em reformas de saúde recentes em países europeus. Na Alemanha, a partir da segunda metade da década de noventa, impulsionadas por pressões econômicas, legislação específica e iniciativas dos próprios prestadores, foram desenvolvidas novas estruturas organizacionais e modelos assistenciais com o propósito de integração do sistema de saúde e a coordenação da atenção, na forma de redes de consultórios médicos, modelo generalista coordenador, programas de gestão clínica para agravos específicos e assistência integrada. A partir de revisão bibliográfica, análise documental, visitas a serviços e entrevistas com informantes-chave, o artigo analisa a dinâmica destas mudanças organizacionais no setor ambulatorial alemão. Examinam-se os mecanismos de integração e coordenação propostos, discutem-se os impactos potenciais das novas modalidades organizacionais sobre a eficiência e a qualidade e analisam-se motivos e interesses envolvidos, apontando obstáculos para a implementação. Observa-se processo de reforma incremental com tendência à diversificação do panorama assistencial na Alemanha, com presença de modelos integrados de atenção e fortalecimento do papel do médico generalista na função de coordenação dos cuidados aos pacientes.

[Quality circles in German ambulatory care: results of a continuous documentation in the regions of Bremen, Saxony-Anhalt, Schleswig-Holstein and Westphalia-Lippe 1995-2007]

BACKGROUND

Quality circles (QC) are viewed as one of the most important tools of quality improvement and continuing education in ambulatory care. Yet, little is known about the quality of QC work.

METHODS

From 1995 to 2007, an external assessment of QC work took place at four regional Associations of Statutory Health Insurance (SHI) Physicians. After each meeting, QC leaders completed questionnaires. This basic documentation focused on important features of QC work--continuity, topics, methods, results and satisfaction.

RESULTS

28,800 meetings in 1,640 quality circles were documented, and 27,255 documents from 1,241 groups analysed. Continuity was high over long periods, and medical topics were dealt with in more than 80% of the time. The use of appropriate methods, however, have room for improvement. Participants were very satisfied.

CONCLUSIONS

For the first time the quality of QC structures, processes and results was assessed in Germany using a broad dataset. The working principles of QC appear to be well-established. Using the basic documentation practical recommendations are made to improve the quality of QC.

Knowledge transfer for the management of dementia: a cluster randomised trial of blended learning in general practice

Background

The implementation of new medical knowledge into general practice is a complex process. Blended learning may offer an effective and efficient educational intervention to reduce the knowledge-to-practice gap. The aim of this study was to compare knowledge acquisition about dementia management between a blended learning approach using online modules in addition to quality circles (QCs) and QCs alone.

Methods

In this cluster-randomised trial with QCs as clusters and general practitioners (GPs) as participants, 389 GPs from 26 QCs in the western part of Germany were invited to participate. Data on the GPs' knowledge were obtained at three points in time by means of a questionnaire survey. Primary outcome was the knowledge gain before and after the interventions. A subgroup analysis of the users of the online modules was performed.

Results

166 GPs were available for analysis and filled out a knowledge test at least two times. A significant increase of knowledge was found in both groups that indicated positive learning effects of both approaches. However, there was no significant difference between the groups. A subgroup analysis of the GPs who self-reported that they had actually used the online modules showed that they had a significant increase in their knowledge scores.

Conclusion

A blended learning approach was not superior to a QCs approach for improving knowledge about dementia management. However, a subgroup of GPs who were motivated to actually use the online modules had a gain in knowledge.

Trial registration

Current Controlled Trials ISRCTN36550981.

General Practitioners' preferences and use of educational media: a German perspective

Background

Several studies suggest that General Practitioners (GPs) prefer "traditional" media such as journals or quality circles when they are seeking out different options to meet their continuing medical education (CME) requirements. A survey was designed in order to gain a better understanding of German General Practitioners' preferences for different forms of educational media that will meet their CME needs.

Methods

Four hundred and forty nine (N = 449) German physicians were contacted to take part in this study on the occasion of one of their quality circle meetings. The participating physicians received a standardized 26-item-questionnaire that surveyed their preferences for different forms of educational media. A factor analysis was performed in order to determine whether the observed variables can be explained largely or entirely in terms of the underlying patterns.

Results

Two hundred and sixty-four physicians with an average age of 51.1 years participated (28.5% female, 71.5% male). We found that GPs favor learning environments such as: journals, colleagues, and quality circles. New media like the internet was used less often for their learning activities, even though the usage of the internet in general was quite high. The most important requirements for media in medical education as perceived by the participants were its relevancy for daily practice and dependability.

Conclusion

Despite a growing use of the Internet it seems that German GPs favor "classical/traditional" settings for their learning activities. These results should be taken into consideration when planning CME or CPD programs or other learning activities.

Trial registration

Current Controlled Trials ISRCTN36550981.

Impact of quality circles for improvement of asthma care: results of a randomized controlled trial

RATIONALE AND AIMS

Quality circles (QCs) are well established as a means of aiding doctors. New quality improvement strategies include benchmarking activities. The aim of this paper was to evaluate the efficacy of QCs for asthma care working either with general feedback or with an open benchmark.

METHODS

Twelve QCs, involving 96 general practitioners, were organized in a randomized controlled trial. Six worked with traditional anonymous feedback and six with an open benchmark; both had guided discussion from a trained moderator. Forty-three primary care practices agreed to give out questionnaires to patients to evaluate the efficacy of QCs.

RESULTS

A total of 256 patients participated in the survey, of whom 185 (72.3%) responded to the follow-up 1 year later. Use of inhaled steroids at baseline was high (69%) and self-management low (asthma education 27%, individual emergency plan 8%, and peak flow meter at home 21%). Guideline adherence in drug treatment increased (P = 0.19), and asthma steps improved (P = 0.02). Delivery of individual emergency plans increased (P = 0.008), and unscheduled emergency visits decreased (P = 0.064). There was no change in asthma education and peak flow meter usage. High medication guideline adherence was associated with reduced emergency visits (OR 0.24; 95% CI 0.07-0.89). Use of theophylline was associated with hospitalization (OR 7.1; 95% CI 1.5-34.3) and emergency visits (OR 4.9; 95% CI 1.6-14.7). There was no difference between traditional and benchmarking QCs.

CONCLUSIONS

Quality circles working with individualized feedback are effective at improving asthma care. The trial may have been underpowered to detect specific benchmarking effects. Further research is necessary to evaluate strategies for improving the self-management of asthma patients.

Acceptance and perceived barriers of implementing a guideline for managing low back in general practice

Background

Implementation of guidelines in clinical practice is difficult. In 2003, the German College of General Practitioners and Family Physicians (DEGAM) released an evidence-based guideline for the management of low back pain (LBP) in primary care. The objective of this study is to explore the acceptance of guideline content and perceived barriers to implementation.

Methods

Seventy-two general practitioners (GPs) participating in quality circles within the framework of an educational intervention study for guideline implementation evaluated the LBP-guideline and its practicability with a standardised questionnaire. In addition, statements of group discussions were recorded using the metaplan technique and were incorporated in the discussion.

Results

Most GPs agree with the guideline content but believe that guideline stipulations are not congruent with patient wishes. Non-adherence to the guideline and contradictory information for patients by other professionals (e.g., GPs, orthopaedic surgeons, physiotherapists) are important barriers to guideline adherence. Almost half of the GPs have no access to recommended multimodal pain programs for patients with chronic LBP.

Conclusion

Promoting adherence to the LBP guideline requires more than enhancing knowledge about evidence-based management of LBP. Public education and an interdisciplinary consensus are important requirements for successful guideline implementation into daily practice. Guideline recommendations need to be adapted to the infrastructure of the health care system.

Trial registration

BMBF Grant Nr. 01EM0113. FORIS (database for research projects in social science) Reg #: 20040116 [25].

What is the role of quality circles in strategies to optimise antibiotic prescribing? A pragmatic cluster-randomised controlled trial in primary care

OBJECTIVE

To evaluate the effect on antibiotic prescribing of an intervention in existing local quality circles promoting an evidence-based guideline for acute rhinosinusitis.

DESIGN

A pragmatic cluster-randomised controlled trial comparing standard dissemination of the guideline by mail with an additional strategy using quality circles.

SETTING

General practice in Flanders, Belgium.

PARTICIPANTS

General practitioners (GPs) in 18 local quality circles were randomly allocated to two study arms. All GPs received the guideline by mail. GPs in the nine quality circles allocated to the intervention arm received an additional group intervention, which consisted of one self-led meeting using material introduced to the group moderator by a member of the research team.

MAIN OUTCOME MEASURES

Adherence to the guideline was measured as differences in the proportion of antibiotic prescriptions, including the choice of antibiotic, between the two study arms after the intervention period. GPs registered their encounters with patients presenting with signs and symptoms of acute rhinosinusitis in a booklet designed for the study.

RESULTS

A total of 75 doctors (29% of GPs in the participating quality circles) registered 408 consultations. In the intervention group, 56.9% of patients received an antibiotic compared with 58.3% in the control group. First-choice antibiotics were issued in 34.5% of antibiotic prescriptions in the intervention group compared with 29.4% in the control group. After adjusting for patient and GP characteristics, the ORadj for antibiotics prescribed in the intervention arm compared with the control arm was 0.63 (95% CI 0.29 to 1.37). There was no effect on the choice of antibiotic (ORadj 1.07, 95% CI 0.34 to 3.37).

CONCLUSION

A single intervention in quality circles of GPs integrated in the group's normal working procedure did not have a significant effect on the quality of antibiotic prescribing. More attention to the context and structure of primary care practice, and insight into the process of self-reflective learning may provide clues to optimise the effectiveness of quality circles.

Impact of support initiatives on retaining rural general practitioners

OBJECTIVE

This study aimed to evaluate the impact of the Dr DOC program, a rural doctor workforce support program, which consists of social and psychological support and practical interventions, on the well-being and retention of rural GPs.

DESIGN

Rural GPs were assessed on different aspects of well-being and their intentions to leave rural general practice, and these were compared with similar data collected two years prior.

SETTING

Rural general practices in South Australia.

PARTICIPANTS

Two hundred and twenty-one rural GPs (55% of South Australian rural GP workforce).

MAIN OUTCOME MEASURES

GPs completed a questionnaire assessing their levels of support, intention to leave rural practice, use of the dr doc program, and psychological health.

RESULTS

Improvements were found in the support networks and in the physical and emotional health of rural GPs from time 1 to time 2. There was also a reduction in the number of GPs wanting to leave rural general practice in the short to medium term (from 30% to 25%).

CONCLUSIONS

The initial study in this series suggested that improving psychological well-being might influence rural GPs' intentions to leave rural practice. The current study confirms these suggestions by demonstrating that programs targeted at psychological and physical well-being do indeed impact on rural GPs' intentions to leave. The results of this study highlight the role of psychological well-being in retaining rural GPs and emphasise the value of developing psychologically based programs to not only boost the physical and mental health of GPs, but also to reduce departure from rural areas.

An educational programme for peer review groups to improve treatment of chronic heart failure and diabetes mellitus type 2 in general practice

RATIONALE, AIMS AND OBJECTIVES

Peer review groups are considered helpful for quality improvement in primary care. An interactive educational programme for small peer groups was developed, focusing on the implementation of newly developed treatment guidelines. The aim is to evaluate the effect of the programme on adherence to treatment guidelines in general practice.

METHODS

A cluster randomized trial using a balanced incomplete block design was used; one arm received a programme on treatment of chronic heart failure (CHF), the other on hypertension treatment in diabetes mellitus type 2 (T2DM). A random sample of 10 CHF and 10 T2DM patients per GP was drawn, for whom data were extracted from electronic patient records 1 years before and 6 months after the intervention. The outcomes were prescribing of ACE inhibitors, and antihypertensive treatment in T2DM. The effect was analysed separately for both programmes using multilevel regression models.

RESULTS

All 27 peer review groups in one region in the Netherlands were randomized, of which 16 participated. No significant effects were observed in the CHF group or in the T2DM group. The opportunity for change was limited, as only 53% of the CHF patients and 60% of the T2DM patients had a contact with their GP between the intervention and follow-up measurement.

CONCLUSION

The peer review programme was not successful for changing the treatment of chronic patients, although the programme focused on dealing with barriers perceived by the participants. Not all problems perceived can be solved in a peer group discussion.

[Primary care in European Union countries: configurations and organizational reforms in the 1990s]

During the 1990s, proposals to contain health expenditures and demands raised by changes in the epidemiological profile led to organizational reforms in primary healthcare services in European Union countries, aimed at promoting the coordination of services provided by the various levels of care. Based on a literature review, document analysis, and interviews with key informants, the current study analyzes the institutional configurations for first-level healthcare and discusses the pre-coordination organizational reforms in the European Union countries. First-level outpatient care is provided in these countries through a wide variety of institutional configurations, observing the different financing mechanisms, range of healthcare professionals, range of clinical services provided, and the position occupied by physicians in primary care within the healthcare system. Reforms in the last decade were accompanied by a diversification in the outpatient care organizational models, with an expansion in the clinical, healthcare coordination management, and financing functions of primary care professionals, indicating a process in transition, with a redefinition of the roles played by general practitioners as the leaders of patient care.

Review of performance assessment and improvement in ambulatory medical care

Health care plans often consider quality of care as a means of containing rising health costs. The assessment of physician and group practice performance has become increasingly widespread in ambulatory care. This article reviews the three main methods used to improve and assess performance: practice audits, peer-review groups and practice visits. The focus is on Europe - which countries use which methods - and on the following aspects: which authorities or bodies are responsible for setting up and running the systems, are the systems mandatory or voluntary, who takes part in assessments and what is their motivation, are patients views taken into account. Many countries run parallel systems managed by authorities working at different hierarchical levels (national, regional or local). The reasons that underlie the choice of a particular system are discussed. They are mostly related to the national health care system and to cultural factors.

A institucionalização da educação permanente no programa de saúde da família: uma experiência municipal inovadora

O Programa de Saúde da Família (PSF), adotado pela Secretaria Municipal de Saúde de Vitória (ES) como estratégia de estruturação da atenção primária, tem exigido de seus profissionais conhecimentos e habilidades em geral não valorizados em sua formação acadêmica. Além disso, a oferta constante de novos conceitos e tecnologias e a demanda da população por um serviço de saúde adequado às suas necessidades requerem do profissional da saúde aperfeiçoamento contínuo. A Secretaria de Saúde do município, respondendo a essas necessidades, implantou em 2001 e institucionalizou em 2003 o Programa de Educação Permanente (PEP) para os profissionais de nível superior das equipes de saúde da família. Esse programa tem pautado sua atuação em uma nova concepção de educação continuada, envolvendo aprendizagem contextualizada baseada em evidências e realizada através de metodologias inovadoras, como a revisão entre pares e a aprendizagem baseada em problemas.

RCGP Quality Team Development programme: an illuminative evaluation

BACKGROUND

There is increasing interest in quality initiatives that are locally owned and delivered, team based, multiprofessional, and formative. The Royal College of General Practitioners' Quality Team Development (QTD) programme is one such initiative aimed at developing primary healthcare teams and their services.

AIMS

To evaluate QTD from the perspective of participants and assessors.

SETTING

UK primary health care.

DESIGN AND METHOD

Twelve of 14 practices and all four primary care organisations (PCOs) approached agreed to participate. Thirty four semi-structured interviews were conducted with key stakeholders. The interviews were taped, transcribed, and analysed using the constant comparative method.

RESULTS

The QTD programme appears to be highly valued by participating organisations. Practice based respondents perceived it as acceptable and feasible, and reported positive changes in teamwork and patient services. They valued its formative, participative, and multiprofessional nature, especially the peer review element. PCOs saw QTD as a method of delivering on prevailing national policies on clinical quality and modernization agendas as well as promoting interorganizational collaboration. The main concerns raised were the workload, particularly for assessors, and maintaining the quality of the assessments and the programme.

CONCLUSION

This qualitative study suggests positive benefits for participants in the QTD programme. However, such practices are a self-selecting innovative minority. Further research is needed on more typical practices to identify barriers to their participation in QTD or other formative, team based quality improvement programmes.

RCGP Quality Team Development programme: an illuminative evaluation

BACKGROUND

There is increasing interest in quality initiatives that are locally owned and delivered, team based, multiprofessional, and formative. The Royal College of General Practitioners' Quality Team Development (QTD) programme is one such initiative aimed at developing primary healthcare teams and their services.

AIMS

To evaluate QTD from the perspective of participants and assessors.

SETTING

UK primary health care.

DESIGN AND METHOD

Twelve of 14 practices and all four primary care organisations (PCOs) approached agreed to participate. Thirty four semi-structured interviews were conducted with key stakeholders. The interviews were taped, transcribed, and analysed using the constant comparative method.

RESULTS

The QTD programme appears to be highly valued by participating organisations. Practice based respondents perceived it as acceptable and feasible, and reported positive changes in teamwork and patient services. They valued its formative, participative, and multiprofessional nature, especially the peer review element. PCOs saw QTD as a method of delivering on prevailing national policies on clinical quality and modernization agendas as well as promoting interorganizational collaboration. The main concerns raised were the workload, particularly for assessors, and maintaining the quality of the assessments and the programme.

CONCLUSION

This qualitative study suggests positive benefits for participants in the QTD programme. However, such practices are a self-selecting innovative minority. Further research is needed on more typical practices to identify barriers to their participation in QTD or other formative, team based quality improvement programmes.